800份病案知情同意书填写质量调查分析

Analysis on 800 Agreements of Acknowledgement of the Medical Record

目的了解我院知情同意书实施的情况。方法抽查我院2003年7-12月出院,需要建立知情同意书的内、外科病案,共800份进行统计。结果在抽查的800份病案中,全部符合要求的581份,占72.6%,存在问题的219份,占27.4%;有40份没有填写知情同意书,有36份只建立在电子病案中,未能及时打印出来让患者签名,无患者或家属签字的有22份。结论写好知情同意书,必须要转变观念,提高对知情同意书重要性的认识,要进一步规范对患方家属签名的要求。

Objective To explore the results of fulfilling of Agreement of Acknowledgement of the Medical Record (TMR). Methods 800 TMRs of internal and surgery wards were spot-checked from all the TMRs from July to December in 2003,based on the needs of signing Agreements of Acknowledgement. Results Among the 800 TMRs, 581 ones (72.6%) reached the standards; 219 ones (27.4%) didn't fit requires. And 40 TMRs had no Agreements of Acknowledgement; 36 ones just had these in Digital Medical Records, and without singing of patients; 22 ones hadn't patient's or dependents' signing at all. Conclusion To finish the Agreement of Acknowledgement, doctors should change their idea to realize its importance, thus strengthen the claims of signing of patients or dependents.